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psnet.ahrq.gov/node/49724/psn-pdf
January 01, 2015 - Bowel Injury After Laparoscopic Surgery
January 1, 2015
Moorthy K. Bowel Injury After Laparoscopic Surgery. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/bowel-injury-after-laparoscopic-surgery
The Case
A 30-year-old man presented to the hospital for a scheduled laparoscopic inguinal hernia repair with mes…
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psnet.ahrq.gov/web-mm/diagnosing-hiv-it-doesnt-take-brain-surgeon
January 01, 2018 - More than 500,000 cumulative deaths in the United States have occurred in persons with the acquired immunodeficiency
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psnet.ahrq.gov/web-mm/delay-treatment-failure-contact-patient-leads-significant-complications
February 01, 2004 - SPOTLIGHT CASE
Delay in Treatment: Failure to Contact Patient Leads to Significant Complications
Citation Text:
Shapiro DS. Delay in Treatment: Failure to Contact Patient Leads to Significant Complications. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Departmen…
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psnet.ahrq.gov/node/49591/psn-pdf
October 01, 2009 - Difficult Encounters: A CMO and CNO Respond
October 1, 2009
Ring EJ, Hirsch JE. Difficult Encounters: A CMO and CNO Respond. PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/difficult-encounters-cmo-and-cno-respond
Case Objectives
Appreciate the risk of disruptive behavior and understand institutional respons…
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psnet.ahrq.gov/web-mm/consequences-medical-overuse
May 05, 2021 - SPOTLIGHT CASE
Consequences of Medical Overuse
Citation Text:
Morgan DJ, Foy AJ. Consequences of Medical Overuse. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
Copy Citation
Format:
Google Scholar BibT…
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psnet.ahrq.gov/web-mm/palliative-care-comfort-vs-harm
December 04, 2016 - SPOTLIGHT CASE
Palliative Care: Comfort vs. Harm
Citation Text:
Jox RJ. Palliative Care: Comfort vs. Harm. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
Copy Citation
Format:
Google Scholar BibTeX EndN…
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psnet.ahrq.gov/web-mm/sudden-collapse-during-upper-gastrointestinal-endoscopy-expect-unexpected
September 25, 2024 - Sudden Collapse During Upper Gastrointestinal Endoscopy: Expect the Unexpected
Citation Text:
Wieck M. Sudden Collapse During Upper Gastrointestinal Endoscopy: Expect the Unexpected. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 202…
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psnet.ahrq.gov/web-mm/suicidal-ideation-family-medicine-clinic
October 01, 2007 - SPOTLIGHT CASE
Suicidal Ideation in the Family Medicine Clinic
Citation Text:
Moutier C. Suicidal Ideation in the Family Medicine Clinic. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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Format:
…
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psnet.ahrq.gov/web-mm/culture-clash-no-more-integration-and-coordination-disease-treatment-and-palliative-care
December 23, 2020 - SPOTLIGHT CASE
Culture Clash No More: Integration and Coordination of Disease Treatment and Palliative Care
Citation Text:
Spero H, Usher AE, Howard B, et al. Culture Clash No More: Integration and Coordination of Disease Treatment and Palliative Care . PSNet [internet]. Rockville (MD): Agency f…
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psnet.ahrq.gov/sites/default/files/2021-09/spotlight_missed_sea_09.17.2021_-_final.pdf
January 01, 2021 - Spotlight
Spotlight
Dangers of Missing an Epidural Abscess:
Multiple Visits and Delayed Diagnosis with
a Severely Negative Outcome
Source and Credits
• This presentation is based on the June 2021 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Comm…
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psnet.ahrq.gov/perspective/conversation-withsorrel-king
March 01, 2007 - With two million hospital infections and 90,000 deaths annually because of hospital infections ( 7 ),
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psnet.ahrq.gov/node/49779/psn-pdf
January 01, 2017 - Between January 2005 and December 2009,
56,000 adverse events and 710 deaths relating to IV infusion
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psnet.ahrq.gov/node/33818/psn-pdf
November 01, 2016 - has been a 17% drop in those hospital-acquired conditions, which has
probably prevented about 87,000 deaths
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psnet.ahrq.gov/perspective/conversation-withallan-frankel-md
July 01, 2006 - In 1997, Newton-Wellesley Hospital had two highly publicized maternal deaths in the space of a week. … Because one of the deaths may have been drug-related, the hospital created a position of medication management
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psnet.ahrq.gov/perspective/conversation-withlucian-leape-md
August 01, 2006 - pointing to major problems in anesthesia safety and a 1982 episode of ABC's 20/20 that dramatized deaths … Yet, those who have lived through the past few decades of anesthesia's evolution know that the deaths
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psnet.ahrq.gov/perspective/key-issues-developing-successful-hospital-safety-program
July 01, 2006 - In 1997, Newton-Wellesley Hospital had two highly publicized maternal deaths in the space of a week. … Because one of the deaths may have been drug-related, the hospital created a position of medication management
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psnet.ahrq.gov/innovation/statewide-telehealth-program-enhances-access-care-improves-outcomes-high-risk
November 13, 2024 - While the national average is approximately 20 maternal deaths per 100,000 live births, Arkansas’ rate … far exceeds that at 35 deaths per 100,000 live birth. 5
Limited health care access as partial
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psnet.ahrq.gov/issue/multi-method-exploratory-evaluation-service-designed-improve-medication-safety-patients
July 22, 2020 - Study
A multi-method exploratory evaluation of a service designed to improve medication safety for patients with monitored dosage systems following hospital discharge.
Citation Text:
Alqenae FA, Steinke DT, Belither H, et al. A multi-method exploratory evaluation of a service designed to…
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psnet.ahrq.gov/issue/association-between-end-rotation-resident-transition-care-and-mortality-among-hospitalized
August 15, 2018 - Study
Association between end-of-rotation resident transition in care and mortality among hospitalized patients.
Citation Text:
Denson JL, Jensen A, Saag HS, et al. Association Between End-of-Rotation Resident Transition in Care and Mortality Among Hospitalized Patients. JAMA. 2016;316(2…
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psnet.ahrq.gov/issue/health-disparities-impact-health-disparities-and-treatment-decision-making-biases-cancer
October 14, 2020 - Commentary
Health disparities: impact of health disparities and treatment decision-making biases on cancer adverse effects among black cancer survivors.
Citation Text:
Vo J, Gillman A, Mitchell K, et al. Health disparities: impact of health disparities and treatment decision-making biase…